I'm surprised to read Pamela's comment that topical abx usually won't treat nipple infection. I'd been doing milk cultures but not swabbing nipples, thinking that systemic meds wouldn't be required for it and using mupirocin  or APNO empirically. 
I'll need to start culturing nipples, perhaps when topical so fail.  Other advice/ experience would be welcome
Melinda Harris-Moulton
IBCLC, FNP

Sent from my iPad

> On May 7, 2016, at 12:25 AM, Pamela Morrison <[log in to unmask]> wrote:
> 
> Molly
> 
> IME the most likely cause of nipple pain and damage that goes on and on is
> a bacterial infection, not thrush, and usually S Aureus.  I usually ask if
> a nipple swab or culture of the milk can be done to establish what the
> organism is and which antibiotic will be effective. When I practised in
> Harare I had a succession of mothers whose nipples tested positive for S
> Pyogenes.  I find that topic antibacterials don't work at all by the way...
> 
> Here are a couple of the articles I've collected over the years:
> 
> Clinical Lactation 2014, at
> http://www.clinicallactation.org/sites/default/files/articlepdf/Article%203%20106-115.pdf
> 
> Stephen Graves' study - cultured pink sore nipples and found mostly
> Staph...treatment
> for Staph eliminated the problem in most cases, and in one third washing
> with soap 2-3x per day was sufficient to eliminate it.
> 
> http://www.racgp.org.au/afp/200307/20030705graves.pdf
> 
> 
> I regret I don't have a link to this, but I believe this was one of the
> first articles to identify staph infections as a more likely cause of
> ongoing nipple damage - Livingstone VH, Willis CE, Berkowitz J.
> Staphylococcus aureus and sore nipples. Can Fam Physician. 1996
> Apr;42:654-9.  This article concluded that mothers with infants younger
> than 1 month who complained of moderate to severe nipple pain and who had
> cracks, fissures, ulcers, or exudates had a 64% chance of having positive
> skin cultures and a 54% chance of having S aureus colonization. There is
> also a high association between staphylococcal infection on the nipple and
> mastitis and nipple damage provides a route of entry into the breast, and
> accompanying nipple pain may predispose to compromised breast drainage by
> shortening breastfeeds and/or lengthening intervals between feeding.
> 
> 
> I hope you can help to expand this doctor's knowledge.
> 
> 
> Pamela Morrison IBCLC
> 
> Rustington, England
> 
>             ***********************************************
> 
> Archives: http://community.lsoft.com/archives/LACTNET.html
> To reach list owners: [log in to unmask]
> Mail all list management commands to: [log in to unmask]
> COMMANDS:
> 1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
> 2. To start it again: set lactnet mail
> 3. To unsubscribe: unsubscribe lactnet
> 4. To get a comprehensive list of rules and directions: get lactnet welcome

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome